This patient always had a few surprises up his sleeve for me. He jerked a thumb over his shoulder at his wife and daughters and asked, “Do you think I will survive all of this?” Before I could respond, he let me know he had a one-million-dollar life insurance policy and the four women in the room were wondering when they would collect. There were loud protestations and comments like, “Oh, Daddy! You are such a pain!” Red-faced and huffing, the ladies instructed me not to believe anything he said. They assured me they didn’t want his money but instead wanted him to survive, bad mannered though he was. He chuckled, and I soon learned incessant teasing was commonplace in this family. To their credit, his wife and daughters gave as well as they received, so there was always interesting and witty repartee among this group.
I scheduled the pilot for an operation a few weeks later. An intraoperative ultrasound demonstrated all six of his liver tumors were in the right lobe of his liver. We do not know why tumors metastasize in the occasionally odd but fortuitous pattern as they had in this man. It was possible to perform a straightforward right-liver-lobe resection and the procedure went without a hitch. There were no issues during his hospital stay and he was on a trajectory to recover well. About the third or fourth postoperative day I stopped by his room for a visit and found him alone. He informed me his wife and daughters had gone downstairs to grab a bite to eat. I pulled up a chair and sat next to his bed and asked, “How long have you been flying?” This simple question led to a lengthy and fascinating answer.
My patient confessed to being a graduate of the United States Naval Academy in Annapolis, Maryland. After graduation, he had gone to naval flight school and qualified to fly fighter jets. Growing up around my grandfather and his two brothers who had fought in World War II, I am a military-history aficionado and I frequently read books about military campaigns. I asked my patient to tell me more and learned he had piloted F-4 Phantoms off an aircraft carrier during the Vietnam War. He had flown numerous ground-support missions and combat sorties over two tours of duty. I asked—thoughtlessly, I realize in retrospect—if he had been involved in any dogfights with enemy MiGs. This usually jocular man became suddenly somber. He replied, “Affirmative. Two combat kills.” He quietly added, “I don’t talk about it much. It means somebody is dying up there. And I lost several friends and members of my air-combat squadron during the war.” Recognizing it was time to change the subject but still enthralled to be sitting with a naval fighter pilot, I asked him to describe what it was like to take off and land on an aircraft carrier. His laugh returned immediately, “That is quite an experience.” He went on to describe the hours of practice and the adrenaline rush associated with landing a jet on the deck. He provided an analogy and a description I will never forget: he said when approaching a carrier at a distance it looks like a postage stamp pitching and bobbing on the waves. He then described the controlled panic of a night landing in heavy seas and remarked comically, “It really tests your underarm deodorant.”
About this time, the patient’s wife and daughters returned, and he informed them we had been talking about his naval flight career. This induced eye rolling and comments from the four females in the room. The merciless taunting resumed, and I knew I had the help of these ladies in goading my patient into a rapid recovery.
The pilot continued to surprise me with tidbits of information. During his first postoperative clinic visit we discussed the necessary documentation to allow him to return to his airline. He noted that he wanted to resume working the following week. I informed him that would be too early to be flying an airplane. He admitted he was one of the senior captains charged with flight-simulator and safety training for his airline. He explained he would be on the ground, sitting at a console, and providing information and feedback to fellow pilots. He had no plans to return to the cockpit for at least three months post-op to assure he was ready to assume flight responsibilities. Satisfied, I replied I had no concerns as long as there was no heavy lifting or strenuous activity related to his duties. Laughing, he let me know there was no physical labor involved and his job was essentially “to scare the living daylights” out of fellow pilots by making sure they were prepared for all kinds of emergency ground and in-flight situations. I could envision this man with his wicked sense of humor deriving considerable pleasure out of tormenting his colleagues. I would learn that I was correct.
I followed the pilot for the next three years with follow-up visits. His blood tests were normal, his liver regenerated quickly to a regular volume, and his CT scans gloriously showed no evidence of recurrent metastatic disease. At every appointment his wife and three daughters were in the examination room with us. After I reported the good news, he invariably turned to them and let them know they would just have to wait for their million dollars. This produced immediate protestation and verbal jousting. He clearly knew how to push their buttons.
Midway through the fourth year of our routine visits I mentioned as an aside that I would be in his home city the following month to attend a surgical meeting. The patient asked if I would be interested in coming to his airline’s flight-simulator facility. He indicated—a little too eagerly, I later realized—he would be happy to show me how they trained and tested pilots. I jumped at this opportunity, and on a Saturday morning I reported slightly early for our 9 a.m. appointment. He gave me a tour of the facility and introduced me to several of the people and the pilots working there. He then shepherded me into a Boeing 737 full-motion flight simulator. This was a large rectangular box sitting atop the heavy hydraulic pistons positioned around it. He informed me instructors could program the simulator to create the illusion of flying or landing in rough weather. He sat in the pilot’s seat and told me to strap in to the co-pilot position. I held on to the yoke as we simulated a takeoff. After a few minutes he nonchalantly said, “Go ahead, make a few turns.” I was thrilled to be flying this simulated aircraft and I completed a few meandering, simple maneuvers. He indicated it was time to “return to the runway” and showed me the checklist and steps involved in landing a commercial airliner. We came in smoothly and uneventfully, and he looked at me and said, “Voilà! That’s how it’s done.” He got up and said, “Sit tight, Doc. I’ll be right back.”
He lied. He went out the door, and I sat waiting for about thirty seconds. Suddenly, the cockpit went dark; the virtual airplane windshield was black and I heard what sounded like rain pelting against the glass. Not possible—the simulator was indoors, wasn’t it? The million-dollar man’s preternaturally calm voice came from a speaker above my head. “Your pilot has just suffered a major medical problem and is incapacitated and unable to assist you. You are landing the plane alone at night in inclement weather. Good luck.” Is he serious? The whole cabin started bucking like a bronco being spurred by a cowboy at the rodeo. I understood immediately why he had made me strap in because I would have been tossed around like an old T-shirt in a dryer had I not been secured to the seat. I looked at the altimeter as he instructed and saw the plane was at four thousand feet and descending. A monotonic female voice came over the cockpit radio and informed me my angle of approach was too low. Holding on to the yoke with a one-handed death grip, I began reducing air speed with the thrust levers as I had seen the pilot do. At the same time I applied the rudder pedals and flaps in an attempt to bring the plane in for a landing. After several minutes of bone-rattling shaking by the simulator, I suddenly saw the display of airstrip lights through the windshield and made corrections to line up on the runway. Each time I corrected, the whole box would shake violently as a simulated crosswind pushed me off course. Thanks for that! The female voice commented several more times on my low landing angle. I wanted to scream at her, “You are not helping!” I restrained myself and concentrated. I am not a pilot, and I have never flown an airplane, but I admit that at that moment I was completely immersed in trying to land this ultimate model airplane safely.
I managed to bring the aircraft in for a bumpy landing. After applying the brakes
and bringing the plane to a halt, admittedly past the end of the simulated runway, my patient’s laughter emanated from the loudspeaker over my head. “What did you think of that, Doc?” His obvious mirth and glee at my rapid heart and respiratory rate were not humorous to me. He opened the door grinning and said, “Hey, you look a little sweaty.” Thanks for the statement of the obvious. I was perspiring like I had just run three miles on a hot Texas summer afternoon. I gained a great deal of respect for pilots that day. I also chided the million-dollar man with some choice words as we walked out, which did nothing but induce more chortling. He informed me several pilots had been in the control room watching, and on their behalf he thanked me for giving them a great show. You’re welcome, always happy to provide some free entertainment.
Cancer is cancer and can rear its ugly head at any time. Almost five years after this gentleman’s liver resection, his previously normal serum tumor marker for colorectal cancer was now elevated. His CT scan showed no tumors in his lungs, liver, or lymph nodes. However, there was a nodule in his right lower abdomen that had not been present before. This was the only abnormality I could detect on the scan. I suspected that this represented the proverbial tip of the iceberg and he likely had a situation called peritoneal carcinomatosis. This means tumor nodules spread throughout the belly cavity have implanted and are growing on the surface of organs in the abdomen and pelvis. Ironically, this was the first visit where only he and his wife were present because his daughters had all assumed he was fine and they no longer needed to come. I reviewed all of the images and test results with the pilot and his wife and shared my concern that this solitary nodule could represent a diffuse return of cancer throughout his abdominal cavity. He asked if I was sure of this and I informed him I was not. Nonetheless, I mentioned while I could remove this tumor, a case could be made to consider chemotherapy first. After a lengthy discussion of the rationale and pros and cons, he nodded and conceded it made sense to him to proceed with chemotherapy.
I called his medical oncologist, who was as disappointed as I upon learning the pilot’s cancer had recurred. The oncologist initiated chemotherapy the next week, and I saw the pilot back three months later. His serum tumor marker had been reduced significantly and the tumor nodule was half the size it had been on previous scans. The patient looked at me and said, “Let’s take it out.” A very matter of fact, direct statement. I expressed hesitation but he noted it was the only spot detected on images, and he wanted to know if there was anything else hiding in his peritoneal cavity. I agreed to perform a laparoscopic exploration of his abdomen during surgery, but informed him this minimalist approach might be somewhat difficult because he had undergone a previous open-colon resection and a subsequent open-liver resection. Some patients after such operations have lots of scar tissue throughout the belly cavity. I mentioned I might be forced to make another open incision to get a good look at all areas. Undaunted, he readily agreed and we scheduled the operation for two weeks later.
Thankfully, he was one of the patients we occasionally see who forms very little scar tissue following abdominal surgery. I was able to get a thorough look at all areas of his peritoneal cavity using the laparoscope. I immediately found the tumor at the tip of the omentum, an apron of fatty tissue, lying in his right lower abdomen. It was a simple and straightforward matter to remove this small piece of fatty tissue and send it for pathological evaluation. Our pathologist froze the tumor, viewed it under the microscope and confirmed it was metastatic colon cancer. I looked at all of my patient’s large and small intestine, the liver, and his stomach, and I even performed a laparoscopic ultrasound of the liver. I could find no additional tumor nodules. I next instilled a liter of sterile saline into his belly cavity through the laparoscopic ports. This is called peritoneal washing. I aspirated all of this fluid out into a canister and sent it to our cytopathologist to assess for the presence of malignant cells. I completed the operation and closed the small laparoscopic incisions.
When I checked on my patient in the recovery room two hours later, he was awake and alert and, as usual, smiling. His wife and three daughters were there at his bedside, the usual jibes being traded among them. As I walked up he shouted loudly enough for most of the patients and staff in the recovery room to hear, “I’m still here and they still don’t get their million dollars!” I loved this guy. He was a naval aviator, a combat veteran, an airline pilot with thousands of hours of experience, and a real clown prince!
The cytopathology report revealed no evidence of additional malignant cells in the peritoneal cavity, a very bizarre situation. I had never before seen a single implant of colorectal cancer like this. Generally, when cancer occurs in the peritoneal cavity it is diffuse and scattered everywhere. We presented this gentleman’s findings at a multidisciplinary tumor board and because his primary tumor responded and shrank with three months of chemotherapy, it was recommended he receive three more months of such treatment. This very reasonable and thoughtful gentleman understood the rationale and agreed to proceed. He completed his chemotherapy without difficulty or problem.
We resumed his follow-up routine. I saw him every four months for the next three years. At a visit into his fourth year of follow-up after the second operation I had performed, I pulled up his lab results, and once again his serum tumor marker was elevated. This time it was much higher than it had been previously. I opened his CT images on the computer and saw that the monster had returned with a vengeance. Now, there were several dozen new lung metastases and enlarged lymph nodes in his chest and along the aorta and inferior vena cava behind his intestines.
I walked forlornly into the examination room shaking my head. The pilot and his family immediately understood. Before I said anything, he turned and grasped his wife’s hand and told her he had expected bad news because he had not been feeling completely normal. I have heard many patients make similar statements when they are diagnosed with seemingly asymptomatic cancer. Even though the patients don’t have any specific symptoms, they somehow sense or know their cancer has recurred. The patient, his wife, and daughters maintained a stoic facade as we discussed the findings and treatment options. I explained this was not a situation we could treat with surgery or any type of radiation therapy. He nodded, understanding, and from the examination room I called his medical oncologist. We discussed this aggressive, albeit somewhat late pattern of recurrence. This patient had already had two types of standard chemotherapy regimens for stage IV colorectal cancer. We weighed numerous options and the patient decided after seeing his medical oncologist the next week to enroll in a clinical trial.
Clinical trials are critical to study new drugs, combinations of agents, or alternative approaches to treat a variety of cancer types. By definition, many of the agents used in clinical trials are new and do not have long-term survival results or response rates. This is a critical mechanism to study new therapies as we continuously seek better treatments to produce better survival rates, and hopefully better quality of life for our patients.
Unfortunately, the pilot’s cancer did not respond after he received a study drug for almost three months. He went from being asymptomatic, looking fit and normal, to a haggard, sallow, and drawn appearance. When I saw him, his wife, and daughters in the office and informed them of the results, he nodded quietly and said, “I’m through.” He told me he wanted no more chemotherapy side effects, and he was content with the additional decade of life he had already gained through two operations and chemotherapy. This was the only time I saw his wife and daughters weep. They did so quietly and with dignity. I sat with the pilot and his family for another thirty minutes, providing what comfort I could and answering tough questions on what to expect as the cancer progressed. I asked him to call me and keep me updated on how he was feeling and getting along. He did call twice in the next two months, but the third call I received was from his wife to report that he had died peacefully at home surrounded by his family.
I was invited to his funeral the next week
but was unable to attend because I had two major liver operations already scheduled that day. I later learned from one of his daughters he had been buried with full military honors, including a flyover by U.S. Navy F/A-18 Hornets from a nearby naval air station. She told me when flying over the cemetery; one plane pulled up vertically and peeled off from the others to signify a missing-man formation. She informed me the church and the funeral service had been packed with hundreds of people who celebrated the life and vitality of the pilot.
Our patients are amazing people. All of them. They are remarkable and they come with occasionally unexpected backgrounds; some are simple salt-of-the earth types, others have incredible past and current occupations or skills and interesting histories and stories to tell. The pilot, the million-dollar man, embodied two virtues I value highly, honor and humor. Two capital H attributes of great worth, I believe. I respect and salute him, and all cancer patients.
27
Great Case
“The quality of a person’s life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor.”
Vince Lombardi
Commitment: The state or quality of being dedicated to a cause, activity, or goal
Humans have different coping mechanisms to deal with stress, fatigue, emotional overload, and repetitive actions in our daily lives. Health-care providers, like people in many other professions, must manage interpersonal interactions and pressure routinely. Sadly, a common stress-minimization method I have noticed among surgeons is actually a bit dehumanizing. The specific coping technique I have witnessed repeatedly ever since I was a medical student is to refer to a patient by the body part of surgical interest rather than the patient’s name. This is ironic because our patients grant us surgeons ultimate trust and access, which is a highly personal experience.
In My Hands Page 21